How We Learn to Speak Up in the Face of Microaggression
Marty Muntz, MD and Kristina Kaljo, PhD
In the face of injustice, academic medicine must lead in the pursuit for equity. We look forward to listening to, learning from, and standing with all of you on this righteous path. To play a meaningful role in societal transformation, however, we in the house of medicine must “take care of our own backyard” by ensuring that our clinical learning environments support inclusivity, collaboration, and character in support of excellence in learning and patient care.
Microaggressions – or “everyday subtle put-downs directed towards a marginalized group in the form of verbal or non-verbal actions” – threaten healthy and robust clinical learning environments. While individual microaggressions may seem minor, their effects are not. Resulting trauma from just one instance can damage an individual’s mental health, decimate team dynamics, and threaten the key outcomes and missions of academic medical centers. Recent scholarship in the detrimental consequences of microaggression can be found here, here, and here.
- Can’t – These situations arise due to poor communication skills, social anxiety, or a lack of understanding of rules and norms. These people are unaware that what they did was hurtful. In medical education, we address these skill deficiencies with observation, teaching, and remediation.
- Oops –These situations arise when good people make mistakes. Conditions ripe for these events might include unrealistic expectations, sleep deprivation, stressful tasks, and emotionally challenging events (sound familiar to anyone in medicine?). Typically, these people have insight and become ashamed and remorseful as they realize they have perpetrated a microaggression.
- Won’t – These situations arise when people disagree with the rules or believe the rules don’t apply to them. They may even pride themselves by taking a stand against the norms, sometimes recalling bygone eras when training was different. These people can be resistant to correction and may compound the microaggression by calling the victim’s toughness or character into question. Senior leadership guidance is typically needed in this category, and we must hold our senior leaders accountable to address these issues quickly and clearly.
In the face of injustice, academic medicine must lead in the pursuit for equity. We look forward to listening to, learning from, and standing with all of you on this righteous path. To play a meaningful role in societal transformation, however, we in the house of medicine must “take care of our own backyard” by ensuring that our clinical learning environments support inclusivity, collaboration, and character in support of excellence in learning and patient care.
As Martin Luther King wrote, “There comes a time when silence is betrayal.” When one remains silent, they become complicit in the resulting damage. This is such a time. We must have and use a common language to address the “can’t, oops, and won’t” events that paralyze our teaching, learning, and advancement of medicine. We must do better.
To Speak-Up, we provide steps to address observed microaggressions safely (see Figure). While practicing common statements may help reduce the threshold to speaking up, significant barriers still exist – especially for students. The power hierarchy that has been central in our clinical learning environment leaves our learners vulnerable to fears that speaking up may result in retribution related to grades and future opportunities for training. These fears are reasonable, because, unfortunately, they are based on a history of such responses. This is unacceptable.
The responsibility to mitigate these situations, then, lies in the hands of leaders. In clinical settings, team leaders begin by reviewing the “nuts and bolts” ground rules of caring for patients on the service, explaining roles of team members, and describing common tasks. However, by also focusing on psychological safety – the “belief that the work environment is safe for interpersonal risk-taking” – team members become empowered. Empowerment is vital to complex and uncertain environments like medicine. Members of psychologically safe teams are more likely to speak up with relevant ideas, questions, or concerns. This openness is vital to achieving shared learning and patient care goals and avoids the tendency of members to focus on “performance” or self-protection.
To Speak-Up, we provide steps to address observed microaggressions safely (see Figure). While practicing common statements may help reduce the threshold to speaking up, significant barriers still exist – especially for students. The power hierarchy that has been central in our clinical learning environment leaves our learners vulnerable to fears that speaking up may result in retribution related to grades and future opportunities for training. These fears are reasonable, because, unfortunately, they are based on a history of such responses. This is unacceptable.
The responsibility to mitigate these situations, then, lies in the hands of leaders. In clinical settings, team leaders begin by reviewing the “nuts and bolts” ground rules of caring for patients on the service, explaining roles of team members, and describing common tasks. However, by also focusing on psychological safety – the “belief that the work environment is safe for interpersonal risk-taking” – team members become empowered. Empowerment is vital to complex and uncertain environments like medicine. Members of psychologically safe teams are more likely to speak up with relevant ideas, questions, or concerns. This openness is vital to achieving shared learning and patient care goals and avoids the tendency of members to focus on “performance” or self-protection.
As soon as the conditions for psychological safety are set, the entire team must be supported and held accountable. When someone recognizes a microaggression and speaks up, the team, and especially the leader, listens and supports the response. When done consistently, teammates develop genuine respect for each other. Eventually each individual on the team feels not only able, but obligated, to challenge uncomfortable situations and bring their best self to work. They trust that this will lead to optimal health and well-being of patients and teammates.
Our MCW medical education community must harness the momentum of the moment to focus on the longstanding scourge of racism in our society and transform our clinical learning environments and our culture at large. Our students learn and practice these concepts in the classroom; we must take further steps to ensure that our clinical learning environments rise to meet their appropriately high expectations.
We suggest that each department examine and discuss the current state of their culture and, through introspection, courageous conversations, and speaking up in challenging situations, transform our clinical learning environments. Our students learn and practice these concepts in the classroom; we must take further steps to ensure that our clinical learning environments rise to meet students’ appropriately high expectations.
Our Kern Institute team stands ready to help plan, facilitate, and evaluate this process to achieve our shared goals and fulfill our promises to learners, patients, and each other. Only after we transform our own backyard can we expect to impact our communities and society.
Our MCW medical education community must harness the momentum of the moment to focus on the longstanding scourge of racism in our society and transform our clinical learning environments and our culture at large. Our students learn and practice these concepts in the classroom; we must take further steps to ensure that our clinical learning environments rise to meet their appropriately high expectations.
We suggest that each department examine and discuss the current state of their culture and, through introspection, courageous conversations, and speaking up in challenging situations, transform our clinical learning environments. Our students learn and practice these concepts in the classroom; we must take further steps to ensure that our clinical learning environments rise to meet students’ appropriately high expectations.
Our Kern Institute team stands ready to help plan, facilitate, and evaluate this process to achieve our shared goals and fulfill our promises to learners, patients, and each other. Only after we transform our own backyard can we expect to impact our communities and society.
Martin Muntz, MD is a Professor of Medicine (General Internal Medicine) at MCW. He is Director of the Curriculum Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.
Kristina Kaljo, PhD is an Assistant Professor and M3 Clerkship Co-Director in the Department of Obstetrics and Gynecology at MCW. She serves in both the Faculty and the Community and Institutional Engagement Pillars of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.
Kristina Kaljo, PhD is an Assistant Professor and M3 Clerkship Co-Director in the Department of Obstetrics and Gynecology at MCW. She serves in both the Faculty and the Community and Institutional Engagement Pillars of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.
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